MRI to Predict Nipple Involvement in Breast Cancer Patients.

OBJECTIVE: The selection of breast cancer patients as candidates for nipple-sparing mastectomy (NSM) is dependent on the preoperative detection of neoplastic involvement of the nipple-areola complex (NAC). This cross-sectional study was designed to evaluate the accuracy of preoperative breast MRI as a noninvasive method to predict neoplastic involvement of the nipple. MATERIALS AND METHODS: We included 165 female breast cancer patients with a surgical plan that included total mastectomy or breast conservation surgery with the removal of the NAC. All patients underwent MRI before surgery on a 1.5-T unit with a 4-channel in vivo dedicated surface breast coil. One radiologist who was blinded to the results of the histologic evaluations of the specimens evaluated the MRI studies. RESULTS: Of the 170 mastectomy specimens evaluated, 37 (21.8%) had neoplastic involvement of the NAC. The MRI findings of enhancement between the index lesion and the NAC and of nipple retraction were considered statistically significant predictors of nipple involvement in breast cancer patients (p < 0.01 and p = 0.01, respectively). The negative predictive value of the combination of these MRI findings was 83.3%. CONCLUSION: Breast MRI is a safe noninvasive method to preoperatively evaluate breast cancer patients eligible for NSM with a high specificity and a high negative predictive value when enhancement between the index lesion and the nipple and nipple retraction are analyzed.

Long-Term Results of Intraoperative Radiation Therapy for Early Breast Cancer Using a Nondedicated Linear Accelerator.

Purpose: To present the long-term results of intraoperative radiation therapy (IORT) for early breast cancer using a nondedicated linear accelerator. Methods and Materials: The eligibility criteria were biopsy-proven invasive carcinoma, age ≥40 years, tumor size ≤3 cm, and N0M0. We excluded multifocal lesions and sentinel lymph node involvement. All patients had previously undergone breast magnetic resonance imaging. Breast-conserving surgery with margins and sentinel lymph node evaluation using frozen sections were performed in all cases. If there were no margins or involved sentinel lymph nodes, the patient was transferred from the operative suite to the linear accelerator room, where IORT was delivered (21 Gy). Results: A total of 209 patients who were followed up for ≥1.5 years from 2004 to 2019 were included. The median age was 60.3 years (range, 40-88.6), and the mean pT was 1.3 cm (range, 0.2-4). There were 90.5% pN0 cases (7.2% of micrometastases and 1.9% of macrometastases). Ninety-seven percent of the cases were margin free. The rate of lymphovascular invasion was 10.6%. Twelve patients were negative for hormonal receptors, and 28 patients were HER2 positive. The median Ki-67 index was 29% (range, 0.1-85). Intrinsic subtype stratification was as follows: luminal A, 62.7% (n = 131); luminal B, 19.1% (n = 40); HER2 enriched 13.4% (n = 28); and triple negative, 4.8% (n = 10). Within the median follow-up of 145 months (range, 12.8-187.1), the 5-year, 10-year, and 15-year overall survival rates were 98%, 94.7%, and 88%, respectively. The 5-year, 10-year, and 15-year disease-free rates were 96.3%, 90%, and 75.6%, respectively. The 15-year local recurrence-free rate was 76%. Fifteen local recurrences (7.2%) occurred throughout the follow-up period. The mean time to local recurrence was 145 months (range, 12.8-187.1). As a first event, 3 cases of lymph node recurrence, 3 cases of distant metastasis, and 2 cancer-related deaths were recorded. Tumor size >1 cm, grade III, and lymphovascular invasion were identified as risk factors. Conclusions: Despite approximately 7% of recurrences, we may infer that IORT may still be a reasonable option for selected cases. However, these patients require a longer follow-up as recurrences may occur after 10 years.

Clinical impact of adjuvant radiation therapy delay after neoadjuvant chemotherapy in locally advanced breast cancer.

BACKGROUND: and Purpose: Post-operative radiation therapy (PORT) is usually indicated for patients with breast cancer (BC) after neoadjuvant chemotherapy (NAC) and surgery. However, the optimal timing to initiation of PORT is currently unknown. MATERIAL AND METHODS: We retrospectively evaluated data from patients with BC who received PORT after NAC and surgery at our institution from 2008 to 2014. Patients were categorized into three groups according to the time between surgery and PORT: <8 weeks, 8-16 weeks and >16 weeks. RESULTS: A total of 581 patients were included; 74% had clinical stage III. Forty-three patients started PORT within 8 weeks, 354 between 8 and 16 weeks and 184 beyond 16 weeks from surgery. With a median follow-up of 32 months, initiation of PORT up to 8 weeks after surgery was associated with better disease-free survival (DFS) (<8 weeks versus 8-16 weeks: HR 0.33; 95% CI 0.13-0.81; p = 0.02; <8 weeks versus >16 weeks: HR 0.38; 95% CI 0.15-0.96; p = 0.04) and better overall survival (OS) (<8 weeks versus 8-16 weeks: HR 0.22; 95% CI 0.05-0.90; p = 0.036; <8 weeks versus >16 weeks: HR 0.28; 95% CI 0.07-1.15; p = 0.08). CONCLUSION: PORT started up to 8 weeks after surgery was associated with better DFS and OS in locally-advanced BC patients submitted to NAC. Our findings suggest that early initiation of PORT is critically important for these patients. However, the low numbers of patients and events in this study prevent us from drawing firm conclusions.

EZH2 Protein Expression and Tumor Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer.

Introduction Neoadjuvant chemotherapy (NAC) is the standard treatment for locally advanced breast cancer. However, some tumors will not respond to this treatment due to histological and molecular features. The protein EZH2 (enhancer of zest homolog 2) is a histone methyltransferase that is correlated with poorly differentiated breast carcinomas and aggressive tumor behavior. Purpose The present study evaluated the association between EZH2 expression and response to NAC, and its correlation with HER2 overexpression, estrogen and progesterone receptors (ER, PR) and Ki-67 proliferation index. Methods A total of 60 patients with locally advanced breast cancer treated with NAC were selected for this study. Twenty-three paraffin blocks had not enough material for tissue resection, and were not evaluated. A tissue microarray based in immunohistochemistry (IHC) analysis of EZH2 was performed for the remaining 37 specimens. Patients were divided into two groups based on response to NAC. Results EZH2 expression was significantly associated with markers of poor prognosis such as ER negativity (p = 0.001), PR negativity (p = 0.042) and high Ki-67 proliferation index (p = 0.002). High EZH2 expression was not correlated with the response to NAC. Conclusions Our data suggested that EZH2 protein expression may not correlate with the clinical response to NAC. Other studies with more patients are needed to confirm this observation.

SPECT-CT-Guided Thoracoscopic Biopsy of Sentinel Lymph Nodes in the Internal Mammary Chain in Patients With Breast Cancer: A Pilot Study.

OBJECTIVE: The objective of this study was to determine the impact of the use of single-photon emission computed tomography fused with computed tomography (SPECT-CT) on thoracoscopic biopsy of sentinel lymph nodes (SLNs) in the internal mammary chain in patients with breast cancer by evaluating resultant changes in staging and their clinical implications. METHODS: Between September 2010 and January 2014, we performed lymphoscintigraphy-assisted thoracoscopic biopsy of the internal mammary chain SLN in 20 patients with breast cancer. Single-photon emission computed tomography fused with computed tomography was also used in 13 of these patients. The sentinel nodes were surgically identified with the aid of a gamma probe. RESULTS: Sentinel lymph nodes were identified surgically in 19 of 20 patients. In the 13 patients in whom SPECT-CT was used, it readily identified SLNs, especially when they were located over an intercostal space. Change of staging occurred in three patients (15%), two of whom accordingly received adjuvant radiotherapy to the internal thoracic chain. CONCLUSIONS: Compared with lymphoscintigraphy alone, the use of SPECT-CT improves localization of the SLN in the internal mammary chain, allowing more accurate planning of each individual's treatment.

Criteria for prediction of metastatic axillary lymph nodes in early-stage breast cancer.

PURPOSE: To estimate the likelihood of axillary lymph node involvement for patients with early-stage breast cancer, based on a variety of clinical and pathological factors. METHODS: A retrospective analysis was done in hospital databases from 1999 to 2007. Two hundred thirty-nine patients were diagnosed with early-stage breast cancer. Predictive factors, such as patient age, tumor size, lymphovascular invasion, histological grade and immunohistochemical subtype were analyzed to identify variables that may be associated with axillary lymph node metastasis. RESULTS: Patients with tumors that are negative for estrogen receptor, progesterone receptor, and HER2 had approximately a 90% lower chance of developing lymph node metastasis than those with luminal A tumors (e.g., ER+ and/or PR+ and HER2-) - Odds Ratio: 0.11; 95% confidence interval: 0.01-0.88; p=0.01. Furthermore, the risk for lymph node metastasis of luminal A tumors seemed to decrease as patient age increased, and it was directly correlated with tumor size. CONCLUSION: The molecular classification of early-stage breast cancer using immunohistochemistry may help predicting the probability of developing axillary lymph node metastasis. Further studies are needed to optimize predictions for nodal involvement, with the aim of aiding the decision-making process for breast cancer treatment.

Breast necrosis induced by the use of coumadin: case report and review of literature.

The coumadin-induced skin necrosis is rare and occurs more frequently in the breasts, thighs and buttocks. We describe the first case of coumadin necrosis of the breast in Brazil in a 62-year-old patient.

Variations in the body mass index in Brazilian women undergoing adjuvant chemotherapy for breast cancer.

PURPOSE: To evaluate variations in the body mass index in patients undergoing adjuvant chemotherapy for breast cancer, and to associate these changes with patient's age and adjuvant chemotherapy regimen. METHODS: We performed a retrospective cohort study in order to correlate any variation in the body mass index before and after adjuvant chemotherapy with patient's age and adjuvant chemotherapy regimen. Patients who received any form of prior hormone therapy, such as tamoxifen or aromatase inhibitors, were excluded. We selected data for 196 patients with stage I to III breast cancer who were treated by radical or conservative surgery and received adjuvant chemotherapy at the Cancer Institute of the State of São Paulo, Brazil. RESULTS: Before adjuvant chemotherapy, 67.8% of patients were classified as overweight or obese according to their body mass indices. Around 66.3% (95% CI 59.7-73.0) of the patients exhibited an increase in the body mass index after adjuvant chemotherapy. The average age of all patients was 56.3±11.3 years. Participants whose body mass index increased were younger than those with no increase (54.7±11.1 versus 59.3±11.2 years; p=0.007). Patients were treated with the following adjuvant chemotherapy regimens: doxorubicin, cyclophosphamide, and paclitaxel (AC-T, 129 patients, 65.8%); 5-fluoracil, doxorubicin, and cyclophosphamide (36 patients, 18.4%); cyclophosphamide, methotrexate, and 5-fluoracil (16 patients, 8.2%); docetaxel and cyclophosphamide (7 patients, 3.6%); and other regimen (8 patients, 4.1%). The AC-T regimen showed a statistically significant association with increase in the body mass index (p<0.001 by ANOVA). CONCLUSIONS: Most patients with breast cancer showed an increase in the body mass index after adjuvant chemotherapy, especially after the AC-T chemotherapy regimen.

Intraoperative radiation therapy in early breast cancer using a linear accelerator outside of the operative suite: an "image-guided" approach.

PURPOSE: To present local control, complications, and cosmetic outcomes of intraoperative radiation therapy (IORT) for early breast cancer, as well as technical aspects related to the use of a nondedicated linear accelerator. METHODS AND MATERIALS: This prospective trial began in May of 2004. Eligibility criteria were biopsy-proven breast-infiltrating ductal carcinoma, age >40 years, tumor <3 cm, and cN0. Exclusion criteria were in situ or lobular types, multicentricity, skin invasion, any contraindication for surgery and/or radiation therapy, sentinel lymph node involvement, metastasis, or another malignancy. Patients underwent classic quadrantectomy with intraoperative sentinel lymph node and margins evaluation. If both free, the patient was transferred from operative suite to linear accelerator room, and IORT was delivered (21 Gy). Primary endpoint: local recurrence (LR); secondary endpoints: toxicities and aesthetics. Quality assurance involved using a customized shield for chest wall protection, applying procedures to minimize infection caused by patient transportation, and using portal films to check collimator-shield alignment. RESULTS: A total of 152 patients were included, with at least 1 year follow-up. Median age (range) was 58.3 (40-85.4) years, and median follow-up time was 50.7 (12-110.5) months. The likelihood of 5-year local recurrence was 3.7%. There were 3 deaths, 2 of which were cancer related. The Kaplan-Meier 5-year actuarial estimates of overall, disease-free, and local recurrence-free survivals were 97.8%, 92.5%, and 96.3%, respectively. The overall incidences of acute and late toxicities were 12.5% and 29.6%, respectively. Excellent, good, fair, and bad cosmetic results were observed in 76.9%, 15.8%, 4.3%, and 2.8% of patients, respectively. Most treatments were performed with a 5-cm collimator, and in 39.8% of the patients the electron-beam energy used was ≥12 MeV. All patients underwent portal film evaluation, and the shielding was repositioned in 39.9% of cases. No infection or anesthesia complications were observed. CONCLUSIONS: Local control with IORT was adequate, with low complication rates and good cosmetic outcomes. More than one-third of patients benefited from the "image-guidance" approach, and almost 40% benefited from the option of higher electron beam energies.

EZH2 Protein Expression and Tumor Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer / Expressão da proteína EZH2 e resposta tumoral à quimioterapia neoadjuvante no câncer de mama localmente avançado

Abstract Introduction Neoadjuvant chemotherapy (NAC) is the standard treatment for locally advanced breast cancer. However, some tumors will not respond to this treatment due to histological and molecular features. The protein EZH2 (enhancer of zest homolog 2) is a histone methyltransferase that is correlated with poorly differentiated breast carcinomas and aggressive tumor behavior. Purpose The present study evaluated the association between EZH2 expression and response to NAC, and its correlation with HER2 overexpression, estrogen and progesterone receptors (ER, PR) and Ki-67 proliferation index. Methods A total of 60 patients with locally advanced breast cancer treated with NAC were selected for this study. Twenty-three paraffin blocks had not enough material for tissue resection, and were not evaluated. A tissue microarray based in immunohistochemistry (IHC) analysis of EZH2 was performed for the remaining 37 specimens. Patients were divided into two groups based on response to NAC. Results EZH2 expression was significantly associated with markers of poor prognosis such as ER negativity (p = 0.001), PR negativity (p = 0.042) and high Ki-67 proliferation index (p = 0.002). High EZH2 expression was not correlated with the response to NAC. Conclusions Our data suggested that EZH2 protein expression may not correlate with the clinical response to NAC. Other studies with more patients are needed to confirm this observation.

Resumo Introdução A quimioterapia neoadjuvante é o tratamento padrão para os cânceres de mama localmente avançados. Entretanto, apenas uma porcentagem desses tumores irá responder ao tratamento, devido a características histológicas e moleculares. A proteína EZH2 (enhancer of zest homolog 2) é uma histona metiltransferase associada a tumores mal diferenciados e de comportamento agressivo. Objetivo O presente estudo teve como objetivo avaliar a associação entre a expressão da proteína EZH2 e a resposta à quimioterapia neoadjuvante, além da correlação dessa proteína com hiper-expressão de HER2, receptores de estrogênio e progesterona, e o marcador de proliferação Ki-67. Métodos Um total de 60 pacientes com câncer de mama localmente avançado tratadas com quimioterapia neoadjuvante foram selecionadas para esse estudo. Vinte e três blocos de parafina não continham material suficiente para ressecção e não foram avaliados. Foi realizado microarray baseado em análise imuno-histoquímica da proteína EZH2 para as 36 pacientes restantes. As pacientes foram divididas em dois grupos baseado na resposta à quimioterapia neoadjuvante. Resultados A expressão da proteína EZH2 foi significativamente associada com marcadores de pior prognóstico, como negatividade para receptor de estrogênio (p = 0,001) e progesterona (p = 0,042), além de alto Ki-67 (p = 0,002). Entretanto, a alta expressão da EZH2 não se correlacionou com a resposta à quimioterapia neoadjuvante. Conclusões Nossos dados sugerem que a expressão da proteína EZH2 pode não estar relacionada com a resposta clínica à quimioterapia neoadjuvante. Outros estudos com maior número de pacientes são necessários para confirmar esses achados.

Breast necrosis induced by the use of coumadin: case report and review of literature / Necrose mamária induzida pelo uso de cumarínico: relato de caso e revisão da literatura

The coumadin-induced skin necrosis is rare and occurs more frequently in the breasts, thighs and buttocks. We describe the first case of coumadin necrosis of the breast in Brazil in a 62-year-old patient.

A necrose cutânea induzida por cumarínicos é um evento raro e ocorre com maior frequência nas mamas, coxas e nádegas. Descrevemos o primeiro caso de necrose cumarínica das mamas no Brasil em paciente de 62 anos.

Criteria for prediction of metastatic axillary lymph nodes in early-stage breast cancer / Critérios para predição de metástases axilares em câncer de mama em estádio clínico inicial

PURPOSE: To estimate the likelihood of axillary lymph node involvement for patients with early-stage breast cancer, based on a variety of clinical and pathological factors. METHODS: A retrospective analysis was done in hospital databases from 1999 to 2007. Two hundred thirty-nine patients were diagnosed with early-stage breast cancer. Predictive factors, such as patient age, tumor size, lymphovascular invasion, histological grade and immunohistochemical subtype were analyzed to identify variables that may be associated with axillary lymph node metastasis. RESULTS: Patients with tumors that are negative for estrogen receptor, progesterone receptor, and HER2 had approximately a 90% lower chance of developing lymph node metastasis than those with luminal A tumors (e.g., ER+ and/or PR+ and HER2-) - Odds Ratio: 0.11; 95% confidence interval: 0.01-0.88; p=0.01. Furthermore, the risk for lymph node metastasis of luminal A tumors seemed to decrease as patient age increased, and it was directly correlated with tumor size. CONCLUSION: The molecular classification of early-stage breast cancer using immunohistochemistry may help predicting the probability of developing axillary lymph node metastasis. Further studies are needed to optimize predictions for nodal involvement, with the aim of aiding the decision-making process for breast cancer treatment. .

OBJETIVO: Estimar a probabilidade de acometimento linfonodal em pacientes com câncer de mama inicial, baseado em fatores clínicos e patológicos. MÉTODOS: Foi realizada uma análise retrospectiva de 1999 a 2007 dos bancos de dados do hospital. Um total de 239 pacientes foram diagnosticados com câncer de mama em estádio inicial. Fatores preditivos como idade, tamanho do tumor, presença de invasão linfovascular, grau histológico e subtipo imunoistoquímico foram analisados para identificar possíveis variáveis associadas com a presença de metástases axilares. RESULTADOS: Pacientes com tumores negativos para receptor de estrogênio, receptor de progesterona e HER2 tiveram aproximadamente 90% menos chance de terem metástases axilares do que pacientes com tumores luminais A (por exemplo, ER+ e/ou PR+ e HER2-) - Odds Ratio: 0,11; intervalo de confiança de 95%: 0,01-0,88; p=0,013. Além disso, o risco de metástases axilares para tumores luminais A diminuiu com o aumento da idade e se correlacionou diretamente com o tamanho do tumor. CONCLUSÃO: A classificação molecular do câncer de mama em estádio inicial utilizando a imunoistoquímica pode ajudar a predizer a probabilidade de encontrar metástases axilares. Novos estudos são necessários para otimizar essa predição, auxiliando no processo de decisão do tratamento relacionado ao câncer de mama. .

Variations in the body mass index in Brazilian women undergoing adjuvant chemotherapy for breast cancer / Variações no índice de massa corpórea em mulheres brasileiras submetidas à quimioterapia adjuvante por câncer de mama

PURPOSE: To evaluate variations in the body mass index in patients undergoing adjuvant chemotherapy for breast cancer, and to associate these changes with patient's age and adjuvant chemotherapy regimen. METHODS: We performed a retrospective cohort study in order to correlate any variation in the body mass index before and after adjuvant chemotherapy with patient's age and adjuvant chemotherapy regimen. Patients who received any form of prior hormone therapy, such as tamoxifen or aromatase inhibitors, were excluded. We selected data for 196 patients with stage I to III breast cancer who were treated by radical or conservative surgery and received adjuvant chemotherapy at the Cancer Institute of the State of São Paulo, Brazil. RESULTS: Before adjuvant chemotherapy, 67.8% of patients were classified as overweight or obese according to their body mass indices. Around 66.3% (95% CI 59.7–73.0) of the patients exhibited an increase in the body mass index after adjuvant chemotherapy. The average age of all patients was 56.3±11.3 years. Participants whose body mass index increased were younger than those with no increase (54.7±11.1 versus 59.3±11.2 years; p=0.007). Patients were treated with the following adjuvant chemotherapy regimens: doxorubicin, cyclophosphamide, and paclitaxel (AC-T, 129 patients, 65.8%); 5-fluoracil, doxorubicin, and cyclophosphamide (36 patients, 18.4%); cyclophosphamide, methotrexate, and 5-fluoracil (16 patients, 8.2%); docetaxel and cyclophosphamide (7 patients, 3.6%); and other regimen (8 patients, 4.1%). The AC-T regimen showed a statistically significant association with increase in the body mass index (p<0.001 by ANOVA). CONCLUSIONS: Most patients with breast cancer showed an increase in the body mass index after adjuvant chemotherapy, especially after the AC-T chemotherapy regimen. .

OBJETIVO: Avaliar variações no índice de massa corpórea em pacientes que estão passando por quimioterapia devido ao câncer de mama, e relacionar tais alterações com a idade da paciente e o regime de quimioterapia. MÉTODOS: Estudo de coorte retrospectivo que correlacionou variações no índice de massa corpórea pré- e pós-quimioterapia com a idade da paciente e o regime de quimioterapia. Foram excluídas as pacientes que receberam terapia hormonal prévia, seja como tamoxifeno ou inibidores da aromatase. Os dados de 196 pacientes com estágio I a III de câncer de mama foram selecionados, e elas foram tratadas por cirurgia radical ou conservadora que receberam quimioterapia adjuvante no Instituto do Câncer do Estado de São Paulo, Brasil. RESULTADOS: Antes da quimioterapia adjuvante, 67,8% das pacientes foram classificadas com sobrepeso ou obesas de acordo com seus índices de massa corpórea. Aproximadamente 66,3% (IC95% 59,7–73,0) das pacientes exibiram aumento no índice de massa corpórea após a quimioterapia adjuvante. A média de idade das pacientes foi de 56,3± 11,3 anos. Pacientes que apresentaram aumento no índice de massa corpórea eram mais jovens do que aquelas que não apresentaram aumento algum (54,7±11,1 versus 59,3±11,2 anos; p=0,007). As pacientes foram tratadas com os seguintes regimes de quimioterapia: doxorrubicina, ciclofosfamida e paclitaxel (AC-T, 129 pacientes, 65,8%); 5-fluoracil, doxorrubicina e ciclofosfamida (36 pacientes, 18,4%); ciclofosfamida, metotrexato e 5-fluoracil (16 pacientes, 8,2%); docetaxel e ciclofosfamida (7 pacientes, 3,6%) e outros regimes (8 pacientes, 4,1%). O regime AC-T mostrou uma relação significativa com o aumento do índice de massa corpórea (p<0,001 por ANOVA). CONCLUSÕES: A maioria das pacientes ...

[Occult metastasis in sentinel lymph node in early-stage breast cancer]. / Metástase oculta em linfonodo sentinela no câncer de mama em estádios iniciais.

PURPOSE: sentinel lymph node biopsy in early-stage breast cancer patients has been substituting the total axillary lymph node is presented dissection. The technique of processing the sentinel lymph node and the aim of this study was to investigate the efficacy of occult metastasis identification based on the standard histological and immunohistochemical examination. METHODS: between 2002 and 2005, 266 sentinel lymph nodes were harvested from axillary biopsy of 170 patients with early stage breast cancer. All lymph nodes were considered to be negative according to standard intra-operative cytological assessment. Lymph nodes were transversally sectioned in four or five slices and embedded in paraffin blocks. Two paraffin-embedded tissue sections with 4 microm in thickness were mounted on glass slides and stained with hematoxylin-eosin and immunoperoxidase (cytokeratin AE1/AE3) techniques. RESULTS: standard histological examination identified metastasis in 22 patients (12.9%) and micrometastatic disease was observed in six of these patients (3.5%). The immunohistochemical examination identified metastatic disease in 16 patients (9.4%). Among them, isolated tumor cells were observed in 11 (6.5%) and micrometastases were identified in five (2.9%). CONCLUSIONS: the association of the standard histological examination and immunohistochemical technique increases the chances of sentinel lymph node metastasis identification.

Metástase oculta em linfonodo sentinela no câncer de mama em estádios iniciais / Occult metastasis in sentinel lymph node in early-stage breast cancer

OBJETIVO: a identificação e biópsia do linfonodo sentinela (LS) no câncer de mama em estádio inicial vêm substituindo a dissecção axilar total. Neste estudo, será apresentada a técnica de processamento do LS, visando o diagnóstico de metástase oculta com base no exame histológico e imuno-histoquímico. MÉTODOS: entre os anos de 2002 e 2005, 266 linfonodos sentinelas foram dissecados em 170 pacientes com câncer de mama em estádio inicial. Foram incluídos apenas os linfonodos considerados negativos durante análise intra-operatória por citologia. Os linfonodos foram seccionados tranversalmente em quatro ou cinco fatias e incluídos em parafina. Em cada bloco de parafina, dois cortes histológicos com 4 µm de espessura foram montados em lâminas para microscopia de luz e corados pela técnica da hematoxilina-eosina e imunoperoxidase (citoqueratina AE1/AE3). RESULTADOS: a avaliação histológica convencional identificou metástase no LS de 22 pacientes (12,9 por cento). Em seis destas (3,5 por cento), o acometimento foi do tipo micrometástase. Já a metástase oculta diagnosticada exclusivamente pela imuno-histoquímica ocorreu em 16 pacientes (9,4 por cento). Em 11 destas (6,5 por cento) foram detectadas células tumorais isoladas e em cinco (2,9 por cento), micrometástases. CONCLUSÕES: a associação do exame histológico de parafina e imuno-histoquímica aumenta a capacidade de identificar metástase oculta no LS de pacientes com câncer de mama em estádios iniciais.

PURPOSE: sentinel lymph node biopsy in early-stage breast cancer patients has been substituting the total axillary lymph node is presented dissection. The technique of processing the sentinel lymph node and the aim of this study was to investigate the efficacy of occult metastasis identification based on the standard histological and immunohistochemical examination. METHODS: between 2002 and 2005, 266 sentinel lymph nodes were harvested from axillary biopsy of 170 patients with early stage breast cancer. All lymph nodes were considered to be negative according to standard intra-operative cytological assessment. Lymph nodes were transversally sectioned in four or five slices and embedded in paraffin blocks. Two paraffin-embedded tissue sections with 4 µm in thickness were mounted on glass slides and stained with hematoxylin-eosin and immunoperoxidase (cytokeratin AE1/AE3) techniques. RESULTS: standard histological examination identified metastasis in 22 patients (12.9 percent) and micrometastatic disease was observed in six of these patients (3.5 percent). The immunohistochemical examination identified metastatic disease in 16 patients (9.4 percent). Among them, isolated tumor cells were observed in 11 (6.5 percent) and micrometastases were identified in five (2.9 percent). CONCLUSIONS: the association of the standard histological examination and immunohistochemical technique increases the chances of sentinel lymph node metastasis identification.

Análise ética do diagnóstico do câncer de mama / Ethical analysis of breast cancer diagnosis

Objetivo: Avaliar o conhecimento e a forma de revelação do diagnósticode câncer em pacientes com câncer de mama atendidas no serviçode mastologia de um hospital universitário de São Paulo. Métodos:Cento e duas pacientes foram entrevistadas entre janeiro de 2003 ejulho de 2004, no dia anterior ao da cirurgia. O pesquisador perguntouse a paciente tinha conhecimento do seu diagnóstico, como este foirevelado e o nível de satisfação das informações obtidas acerca dasua doença. Resultados: Vinte pacientes (19,6%) não sabiam do seudiagnóstico. Houve uma associação significativa entre baixo nível deescolaridade (p = 0,027), idade avançada (p = 0,014) e maior taxa denão conhecimento do diagnóstico. Entre as 82 pacientes informadasdo diagnóstico de câncer, 70 (85,4%) se mostraram satisfeitas da forma como este foi revelado e 12 (14,6%) insatisfeitas. A insatisfaçãodemonstrou associação significativa com baixo nível de escolaridade(p = 0,012). Conclusão: A maioria das pacientes entrevistadas sabiado seu diagnóstico e estava satisfeita com a forma de revelação.O não conhecimento do diagnóstico se relacionou com idade avançadae baixo nível de escolaridade, assim como esta condição tambémdemonstrou associação com insatisfação da forma de diagnóstico.

Acurácia do linfonodo sentinela em pacientes com câncer inicial da mama tratada com quimioterapia neoadjuvante / Sentinel lymph node accuracy in early breast cancer treated with neoadjuvant chemotherapy

Objetivo: avaliar a capacidade preditiva do estudo do linfonodo sentinela (LS) em relaçäo ao estado linfonodal axilar em pacientes com carcinoma invasor inicial de mama submetidas ou näo a quimioterapia neoadjuvante. Métodos: foi realizado estudo prospectivo de 112 pacientes, que foram divididas em dois grupos. O primeiro grupo foi constituído por 70 pacientes que näo receberam quimioterapia prévia (Grupo I) e o segundo foi formado por 42 pacientes que foram submetidas a quimioterapia neoadjuvante, com três ciclos do esquema AC (adriamicina + ciclofosfamida) (Grupo II). A resposta à quimioterapia foi parcial > 50 por cento em 21 pacientes, sendo que em três foi completa, e parcial < 50 por cento em 19 pacientes; em duas pacientes houve progressäo da doença. Procedeu-se à injeçäo peritumoral de dextram marcado com 99mTc. A mesma foi realizada com auxílio de estereotaxia em 29 pacientes com tumores näo palpáveis, sendo 16 do grupo I e 13 do grupo II. Os acúmulos radioativos demonstrados por cintilografia orientaram a biópsia do LS axilar, com auxílio de probe portátil. O estudo anatomopatológico dos LS compreendeu inicialmente um único corte histológico. Os LS livres foram submetidos a cortes seriados a cada 50 µm e corados por HE. Resultados: o LS foi identificado em 108 pacientes. Em três pacientes do grupo I e em uma do grupo II, nas quais näo se obteve identificaçäo do LS, as lesöes näo eram palpáveis. A acurácia do método na prediçäo do estado linfonodal axilar foi de 100 por cento no grupo de pacientes que näo receberam quimioterapia neoadjuvante e de 93 por cento naquele em que esta forma de tratamento prévio foi utilizada. Essa diferença se mostrou estatisticamente significante. Conclusöes: o presente trabalho possibilitou-nos concluir que em todas as pacientes que näo receberam tratamento quimioterápico prévio o estudo do LS foi eficaz para predizer o estado dos linfonodos da axila. A taxa de resultados falso-negativos no grupo de pacientes submetidas à quimioterapia neoadjuvante para invalidar o emprego do estudo do LS nas mesmas.

Emprego concomitante da localizaçäo radioguiada da lesäo e do estudo do linfonodo sentinela para o carcinoma invasor de mama näo palpável / Nonpalpable infiltrative breast cancer: concomitant use of radioguided occult lesion localization and sentinel lymph node biopsy

Objetivo: analisar o emprego concomitante da localizaçäo radioguiada de lesäo näo palpável e do estudo do linfonodo sentinela (LS) em mulheres com câncer de mama. Método: estudo prospectivo de 45 pacientes com carcinoma näo palpável de mama. O radiofármaco utilizado foi o dextram marcado pelo 99mTc. Realizou-se injeçäo no sítio peritumoral, sob orientaçäo ultra-sonográfica ou estereotáxica, com auxílio de agulha de raquianestesia de gauge 18. A linfocintilografia, para visualizaçäo pré-operatória do local da lesäo e do LS, foi feita em gama câmera convencional, com abduçäo de 90º do membro superior ipsilateral. A exérese da lesäo primária e a do LS foram realizadas com auxílio de sonda de detecçäo de radiaçäo gama. Resultados: quanto à remoçäo do tumor primário, obteve-se taxa de sucesso em todos os casos. Houve necessidade de ampliaçäo de margem cirúrgica em cinco pacientes. Em relaçäo ao LS houve falha em quatro casos, com índice de localizaçäo de 93 por cento. Näo foram observadas complicações. Conclusäo: os resultados obtidos parecem demonstrar que a utilizaçäo simultânea dos dois procedimentos constitui estratégia eficaz para o tratamento do câncer inicial de mama em uma única sessäo